and information on how to obtain approval within an organization.35


Simulation and


working under the guidance of another clinician with tube placement experience are also useful for RDNs seeking to become competent in tube placement.35-37 Benefits associated with RDN feeding tube placements will vary by organi-


zation based on which elements require improvement. Several RDNs who place feeding tubes have demonstrated positive outcomes including improved timeliness of tube placement and initiation of EN, a higher success rate with tube placement into the small bowel, and a reduction in the number of x-rays for confirmation of tube location.33,38-40


While RDN tube placement may not be an option for some orga-


nizations, the opportunity warrants exploration, especially if the current practice is causing delayed EN, inadequate EN delivery due to intolerance of gastric feedings, or inappropriate PN use because of lack of ability to place a small bowel feeding tube. RDNs can be the “one-stop shop” for nutrition support when both OW privi-


leges and tube placement are under their scope of practice within an organization. Imagine a severely malnourished patient who is not tolerating gastric feedings. In some organizations, without an RDN tube placement team, the patient (who has already gone some period without adequate nutrition) may have to wait a day or more for tube placement in the radiology department. Or the patient may receive PN because small bowel feeding tube placement is not an option. In an organization with an RDN involved in tube placement, the RDN is already aware of the severity of malnutrition and lack of EN adequacy. The RDN can communicate this information to the health care team, get approval and an order for a tube placement, place the tube, obtain an x-ray if necessary, and then order EN feeding within the same day. RDNs who can practice at a higher level in collaboration with the health care team to ensure patients receive the nutrition they need are highly valued by the rest of the health care team.


Related Nutrition Support Practice Changes


Along with OW privileges, CNMs and RDNs can implement other practices aimed at optimizing EN delivery. Volume-based EN (as opposed to rate-based EN) has been shown to safely and effectively improve EN delivery in multiple studies involving both medical and surgical patients.41-46


Volume-based EN involves an EN order for a


24-hour period rather than specifying an hourly rate. For example, a traditional rate- based order directs the nurse to infuse 60 mL/h without any means to compensate for EN cessation. Conversely, an example of a volume-based order directs the nurse to deliver 1,440 mL during a 24-hour period. If EN is held due to procedures, tests, or surgery, the nurse is provided with guidance on increasing the rate of infusion to make up for EN cessation.41,42


While this may seem to be a logical and practical


approach, it is not familiar or intuitive for many nurses. Gastric residual volume (GRV) monitoring has long been a practice to assess


EN tolerance and prevent aspiration. However, routine GRV monitoring is no longer recommended.47,48


Studies have shown that eliminating routine GRV checks


improves EN delivery without increasing complications such as aspiration, pneu- monia, and mortality.49-51


CHAPTER 4: Clinical Nutrition Management


91


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